Education And Debate

NHS and the Health and Social Care Bill: end of Bevan's vision?

BMJ 2003; 327 doi: (Published 23 October 2003) Cite this as: BMJ 2003;327:982
  1. Allyson M Pollock, professor1,
  2. David Price, senior research fellow1,
  3. Alison Talbot-Smith, specialist registrar in public health1,
  4. John Mohan, professor2
  1. 1Public Health Policy Unit, School of Public Policy, University College London, London WC1H 9QU
  2. 2Department of Geography, University of Portsmouth, Portsmouth, Hampshire, PO1 2UP
  1. Correspondence to: A M Pollock
  • Accepted 7 October 2003

Although the Labour government has repeatedly pledged its commitment to the NHS, its latest reforms pave the way for multiple providers of health care

The Health and Social Care (Community Health and Standards) Bill 2003 is the most controversial piece of legislation to come out of the government's 10 year strategy for the NHS in England.1 The bill, which abolishes government control of NHS trusts by turning them into competing independent corporations called foundation trusts, is a major policy reversal. It could lead to considerable local variation in services and endangers one of the NHS's founding principles–to provide equal care for equal need.

What are foundation trusts?

The new bill allows both NHS and non-NHS bodies, including private companies, to apply to become foundation trusts. Although their principal purpose is to provide goods and services to the NHS, they will be able to carry out any type of business. With guaranteed independence from direct government control, their sole statutory general duty will be to operate “effectively, efficiently, and economically.” They will not have shareholders but will be expected to make and retain surpluses for new investment or for servicing loans raised on the financial markets.2 The scale of such borrowing will depend on their ability to make surpluses.3 The government has given them several new powers to generate surpluses (box 1). These powers, taken together with changes to the methods of allocating resources,4 threaten to destabilise the provision of health services and systematically widen inequalities of access to care.

In the face of growing opposition to the bill from the BMA, trade unions, and the public, the government claims that regulatory safeguards in the bill will protect the core principles of universality and access on the basis of need (see However, as we show below, careful scrutiny shows that …

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